HomeMy WebLinkAboutBLD1989-00491 410 An,
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BUILDING 'ERMIT APPLICATION jf1e)c PIMA ILiA
Jefferson County Building DepartmentSP .O . Box 1220'Port Townsend, WA� 98368'
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LOCATION 4. Lu1)L 1 i
oGO - J e1 rIlrr V'�I1 e - at 1
ii-SPECIFIC LOCATION SITE ADDRESS SCUM � -` GZ
POSTAL DISTRICT /SUBD I V I S IONi'il wV'f 1Or 1/1I ( e
^ DIVISION TAX NUMBER
LEGAL DESCRIPTION LOT /((// BLOCK -
PARCEL NUMBER Ra.I 17 - 1 / 4 SECTION f
PLANNING AREA SECTION l7 TOWNSH i P qpg/ NORTH RANGE / i WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY KNEW BUILDING MAIN FLOOR (gr39-1# 5�----n,
El MOBILE HOME ❑ ADDITION 2ND FLOOR (311-.50 •
❑ MODULAR HOME ❑ ALTERATION BASEMENT
'( DETACHED/ATTACHED ❑ REPAIR CARPORT
GARAGE ❑ REPLACEMENT GARAGE Rif°. ,50
❑ WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
yl MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS 2,
MOBILE HOMES q
O COMMERCIAL SIZE e3q ) �. ;3 5 R 1 '"\ ®
❑ INDUSTRIAL
YEAR 4 @ ; 1 6 /5cl . dD -1.,
❑ HOTEL/MOTEL/DORMITORY MAKES c1i ; 8 "``
NUMBER OF UNITS R i @ ;9 (07a1/4 0
[] OTHER - SPEC1FY ESTIMATED COST OF
It IMPROVEMENTS ,,-,
fOIT( l� FAIR RKET VALUE
UBC OCCUPANCY GROUT ; t O1
SELECTED CHARACTERISTICS OF BUILDING .
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
X WOOD FRAME A ELECTRICITY ❑ COLLECTIVE SOLAR
•
❑ MANUFACTURED ❑ WOODSTOVE ❑ PASSIVE SOLAR ( "
O STRUCTURAL STEEL ❑ GAS ❑ COAL 7Pr 0 (►IeQb"aVre c
❑ REINFORCED CONCRETE ❑ OIL MOTHER - SPEC i rY -- tPri U't'
I
❑ MASONRY ( WALL BEARING ) DIMENSIONS 1
CIOTHER - NUMBER OF STORIES 2 TOTAL LAND AREA 4
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS I
N IN i PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
Lii ND 1 V I DUAL ( SEPT 1 C ) NUMBER of PROPOSED BATHIJM 4,7
APPROVED ATE ❑ I ND I V I DUAL WELL NUMBER OF EXISTING BATIROOM_,
PUD TYPE OF WATER SUPPLY ref
X PUBLIC ( NAME Or WATER SUPPLY) LUO1' DW Water -A-A
APPROVED DATE 30 PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
lA NO Q
APPROVED DATE BANK HEIGHT SETBACK c
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED ❑ YES ❑ NO
IDENTIFICATION
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NAME MAILING ADDRESS ZIP T E L NO
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4 137V0
CONT
.
ARCH 1
ME OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
41CNAT OF A APPLI ATI N DATE RECEIPT NUMBER CHECK NUMBER OR CASH
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ROy PERMI�TJ FEES
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BASE FEE INSPECTION
A G 2 2 iS/O� BLDG SURCHARGE PLAN CHECK
JEFFERSON COUNTY /S ,(" �-' ENERGY SURCHARGE Q TOTAL
PLANNING et BLDG DEPT ,I, WWW 50
9 " NUMBER nEruND DATE F I SSILJ 1/
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